CDC urges precautions during L&D to prevent Zika transmission

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Health care providers working in labor and delivery rooms should employ the standard precautions for infection control to reduce the theoretical risk of Zika transmission, according to recommendations from the Centers for Disease Control and Prevention.

“Because of the potential for exposure to large volumes of body fluids during the labor and delivery process and the sometimes unpredictable and fast-paced nature of obstetrical care, the use of Standard Precautions in these settings is essential to prevent possible transmission of Zika virus from patients to health care personnel,” Dr. Christine K. Olson and her colleagues at the CDC wrote in the Morbidity and Mortality Weekly Report.

No cases of occupational transmission of Zika via bodily fluids have been reported so far, but sexual transmission has occurred and the virus’s RNA has been found in blood, urine, saliva, and amniotic fluid. The risk of occupational exposure therefore theoretically exists, the authors wrote (MMWR. 2016 Mar 22. doi: 10.15585/mmwr.mm6511e3er).

The standard precautions are aimed at preventing transmission of any infectious agent present in blood, body fluids, secretions, nonperspiration excretions, nonintact skin, and mucous membranes. They include five main elements: hand hygiene, use of personal protection equipment (PPE), respiratory hygiene and cough etiquette, safe injection practices, and safe handling of potentially contaminated equipment or surfaces in the patient environment.

Standard PPE recommendations in labor and delivery rooms include eye protection during deliveries to prevent contamination from blood and bodily fluids and the use of double-gloving since the outer layer often contains perforations.

Health care personnel should already be following these standard precautions in all health care settings, but the CDC report will likely remind providers of the importance of these infection control procedures and improve compliance, said Dr. Aaron Caughey, chair of the department of obstetrics and gynecology and associate dean for Women’s Health Research and Policy at Oregon Health and Science University, Portland.

“Those are the standard recommendations on every labor floor for delivery currently, so absolutely it’s feasible,” he said in an interview. However, “for a low-risk woman doing a vaginal delivery without complications, I know that some people skimp on eyewear, and I know there are occasionally people who will wear just one pair of gloves,” he said.

The CDC report also noted varying levels of adherence to the standard precautions.

“Numerous barriers to the appropriate use of PPE have been cited, including the perception that PPE is uncomfortable and limits dexterity, fogging of goggles or face masks, the misperception that prescription eyeglasses provide adequate eye protection, lack of available PPE, forgetting to use PPE, lack of time in urgent clinical situations to don appropriate PPE, the perception that the patient poses minimal risk, and concerns about interference with patient care,” Dr. Olson and her colleagues wrote.

Dr. Caughey drew parallels to the late 1980s and early 1990s, when compliance with eye safety and glove safety precautions increased dramatically alongside the HIV epidemic.

“With these recommendations, it will probably get a little more heightened, particularly if there are parts of the country where Zika becomes endemic,” he said. “The big difference with Zika is if a man contracts Zika or a woman who’s not pregnant contracts Zika, the risks to them are very, very low. It’s really about pregnant women and the risk to the fetus.”

The CDC authors specifically noted that the theoretical risk for Zika transmission is most relevant for female health care personnel who may be pregnant, or for male or female health care personnel attempting to conceive. They recommended that personnel determine the most appropriate PPE based on the likelihood of body fluid exposure for each type of procedure or activity.

An amniotomy or placement of an intrauterine pressure catheter may require mask, eye protection, gloves and an impermeable gown, for example, but vaginal exams of pregnant women with minimal cervical dilation and intact membranes likely only call for the use of gloves. Anesthesia providers should wear sterile gloves and a surgical mask when they place catheters or administer intrathecal injections, and all providers should wear double gloves while handling sharps.